Compliance Plan - P3 Health Partners · P3 is committed to providing high quality health care services in compliance with all applicable laws and regulations. All P3 workforce members

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Compliance Plan

Department: Compliance, Corporate Policy No: 167

Prepared By: Emily Coriale / June 1, 2018 Date Originated: 6/1/2018

Approved By: Compliance Committee – June 26, 2018 Last Revision Date: N/A

Areas of Impact: All P3 Employees and Departments Supersedes P&P No. N/A

1. PURPOSE:

The physicians and workforce of P3 Health Group Holdings, LLC (“P3”)1 are committed

to ensuring compliance with all state and federal laws related to the provision of medical and

management services including all federal and state laws regarding fraud, waste and abuse

(“FWA”). These laws include, but are not limited to, those summarized in Appendix A. This Plan

of Compliance (“Compliance Plan”) sets forth the commitment of the workforce of P32 to abide

by those federal and state laws.

The Compliance Plan is developed in part from the guidance provided by the Office of

Inspector General (“OIG”). The OIG has identified the following seven core components of an

effective compliance program which have been incorporated into this Compliance Plan:

• Conducting internal monitoring and auditing;

• Implementing compliance and practice standards;

• Designating a compliance officer or contact;

• Conducting appropriate training and education;

• Developing open lines of communication;

• Responding appropriately to detected offenses and developing correction action; and

• Enforcing disciplinary standards through well-publicized guidelines.

1 When the term “P3” is used herein, it also includes the following entities, in addition to P3 Health Group Holdings,

LLC (“Holdings”) – P3 Health Partners, LLC; P3 Health Group Management LLC; P3 Consulting, LLC; P3 Health

Partners-Nevada, LLC; Kahan Wakefield Abdou, PLLC; Bacchus Wakefield Kahan, PC; as well as any direct or

indirect subsidiaries of Holdings, whether now existing or hereafter formed. 2 “Workforce” includes all P3 employees and independent contractors providing services to P3 or for the

benefit of P3, including physicians, other healthcare providers, subcontractors, vendors, participating

providers, suppliers, first-tier, downstream and related entities (“FDRs”); and agents (these entities and

vendors are collectively referred to as “Business Partners”).

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2. SCOPE:

a. This policy applies to all P3 employees, management, contractors, student interns, and

volunteers.

b. This policy describes P3’s objectives and policies in establishing its Compliance Plan.

3. DEFINITIONS:

Unless defined in the body of this policy (which would be indicated by a term in parenthetical,

underlined and with quotations around the defined term), the following terms, have the

following meanings for this policy:

Board of Managers: P3’s Board of Managers.

Client Plan Sponsor: Any entity that holds a contract directly with CMS that is involved with

the Medicare Advantage (“MA”) benefit or Part D benefit, and who contracts with P3 to

provide certain services (e.g., Blue Cross Blue Shield of Arizona).

Committee: P3’s Compliance Committee.

Compliance Officer: P3’s compliance officer and his or her designee(s).

Downstream Entity: Any party that enters into a written arrangement, acceptable to CMS,

with persons or entities involved with the MA benefit or Part D benefit, below the level of the

arrangement between an MAO or applicant or a Part D plan sponsor or applicant and a first

tier entity. These written arrangements continue down to the level of the ultimate provider of

both health and administrative services.

FDR: First Tier, Downstream or Related Entity.

Fraud: Knowingly and willfully executing, or attempting to execute, a scheme or artifice to

defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses,

representations, or promises) any of the money or property owned by, or under the custody or

control of, any health care benefit program.

First Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with

a MA Organization (“MAO”) or Part D plan sponsor or applicant to provide administrative

services or health care services to a Medicare eligible individual under the MA program or Part

D program.

Related Entity: Any entity related to a MAO or Part D sponsor by common ownership or

control and:

1. Performs some of the MAO or Part D plan sponsor’s management functions under contract

or delegation;

2. Furnishes services to Medicare enrollees under an oral or written agreement; or

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3. Leases real property or sells materials to the MAO or Part D plan sponsor at a cost of more

than $2,500 during a contract period.

Waste: The overutilization of services, or other practices that, directly or indirectly, result in

unnecessary costs to the Medicare program. Waste is generally not considered to be caused by

criminally negligent actions but rather the misuse of resources.

4. POLICY / PROCEDURE / ACTION:

I. Conducting Internal Auditing and Monitoring.

P3 shall conduct effective and appropriate auditing and monitoring to ensure adherence to

the Compliance Plan, to ensure that the Compliance Plan is current and accurate and that the

Compliance Plan is effective in ensuring that all P3 workforce are appropriately carrying out their

responsibilities and that claims are being submitted properly.

P3 shall engage in two primary types of audits as follows:

Standards and Procedures Audit

P3 shall conduct periodic reviews, at least once annually, of P3’s standards and procedures

to ensure all such standards and procedures are current and complete. Should such an audit reveal

that standards or procedures currently in place are either ineffective or outdated, P3 shall update

the same to reflect any necessary changes. Such audits will be conducted in accordance with P3’s

Audit Protocols.

Claims Submission Audit

Consistent with P3’s Audit Protocols, a routine audit will be conducted a minimum of once

a year of P3’s compliance with applicable coding, billing and documentation requirements,

including P3’s Billing and Coding Compliance Policy. Such an audit shall include a retrospective

review of claims submitted and the documentation supporting such claims to ensure compliance

with state and federal laws as well as P3’s internal policies and procedures. Such audits may be

used as a benchmark against which futures audits may be measured.

Should an audit reveal a concern of non-compliance or if a complaint has been made

regarding possible non-compliance with the Compliance Plan, a more focused audit will be

conducted to investigate the scope of the potential non-compliance.

Where monitoring, auditing or an investigation detects possible non-compliance with the

Compliance Plan or federal or state laws and regulations, including any fraud, waste and abuse

law, the responsible workforce members will be notified. In accordance with P3’s Audit Protocols,

a more focused audit to assess the scope of the potential non-compliance may be conducted.

Additionally, P3 will comply with all mandatory federal reporting requirements and take other

such other corrective measures as necessary to address any compliance violations.

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The Compliance Committee shall review and trend outcomes of FWA and compliance

activity to ensure that the issue will be prevented from reoccurring.

II. Implementing compliance and practice standards.

P3 is committed to providing high quality health care services in compliance with all

applicable laws and regulations. All P3 workforce members must comply with the Compliance

Plan, P3’s policies and procedures, Code of Conduct, and P3’s Billing and Coding Compliance

Policy as may be amended from time-to-time. These various policies help to guide P3’s workforce

members in upholding the highest standards in regard to the provision of quality care, their

interactions with fellow workforce members and helps to ensure P3 engages in proper coding and

billing; that claims are only submitted for reasonable and necessary services; that documentation

for each patient is complete and accurate; and improper inducements, kickbacks and impermissible

referrals are avoided.

In addition to the above, P3’s commitment to providing high quality healthcare services in

compliance with all applicable laws and regulations demands that P3 establish and maintain high

standards of ethical conduct, both on a business and personal level. P3 workforce members are

expected to abide by the following basic tenets in all activities for P3:

Compliance is a team effort; all workforce members are expected to read,

understand and abide by the Compliance Plan and all P3 policies and

procedures. P3’s Compliance Plan will assist P3’s workforce members in

identifying and resolving ethical, legal and compliance issues.

Any compliance issues should immediately be brought to the attention of a

supervisor or the Compliance Officer. If a workforce member is unsure

whether to make a report of potential non-compliance, they should err on

the side of reporting an issue so that it can be assessed and resolved. Reports

of potential non-compliance may be made anonymously by phone to the

Compliance Officer. Additionally, anonymous reports may be made in

writing by placing such reports in the locked “Suggestions” box located in

the patient waiting area. Last, P3 has a compliance hotline that is available

24 hours a day, 7 days a week and 365 days per year. If a workforce member

believes that there has been a compliance issue, he or she can call the hotline

at (844) 680-0872. The Compliance Officer will investigate each report and

engage in appropriate follow-up.

P3 will not take action against workforce members for reporting potential

violations. However, if a P3 workforce member knows of a potential

violation and fails to report the same, the workforce member may be subject

to disciplinary action. Violations of P3’s policies and procedures, including

this Compliance Plan, will also subject workforce members to disciplinary

action up to, and including, termination.

The Compliance Plan, Code of Conduct and other P3 policies and

procedures are intended to provide guidance for workplace conduct, but

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cannot address every potential compliance situation. All P3 workforce

members are expected to exercise good judgment and personal integrity in

every situation, whether or not there is specific guidance in the Compliance

Plan, Code of Conduct or other policy.

III. Designating a compliance officer or contact.

P3 has appointed a Compliance Officer, as noted below, to implement, monitor and enforce

the Compliance Plan. The Compliance Officer will report directly to the Board of Managers. The

Compliance Officer has the authority to review all information of P3 related and relevant to

compliance activities. The Compliance Officer will consult with P3’s legal counsel, as needed.

Specifically, it is the Compliance Officer’s duty to:

1. Be familiar with all laws and regulations applicable to P3’s compliance

activities;

2. Provide leadership for P3’s compliance activities;

3. Update P3’s Compliance Plan with the assistance of P3’s legal counsel and

with the approval of P3’s management;

4. Provide periodic trainings to P3’s workforce regarding the Compliance Plan

and other compliance-related activities;

5. Ensure that all existing and potential P3 employees/contractors/vendors

have been checked through the HHS-OIG List of Excluded Individuals and

Entities and the General Services Administration’s List of Parties Debarred

from Federal Programs. The purpose of this review is to assure individuals

or entities on such lists do not enter into arrangements or agreements with

P3. Each new workforce member will be checked on this list upon hire and

thereafter monthly;

6. Provide each new P3 workforce member with a copy of the Compliance

Plan immediately upon their employment/engagement with P3, answer any

related questions and ensure that the workforce member signs an

acknowledgement that he or she has read and understands the Compliance

Plan;

7. Receive and investigate reports of potential compliance violations and make

recommendations to P3’s management about appropriate corrective and/or

disciplinary actions; and

8. Maintain records related to compliance activities, including records of

training activities, complaints, investigations, etc.

The implementation and success of P3’s Compliance Plan does not fall solely to the

Compliance Officer. It is the responsibility of each P3 workforce member to fully participate in

and commit to compliance activities.

P3 has appointed Maria Nutile as its Compliance Officer. The Compliance Officer

may be reached at 702-307-4880 or via e-mail at [email protected]. Moreover, P3 has a

compliance hotline that is available 24 hours a day, 7 days a week and 365 days per year. If

you believe that there has been a compliance issue, you can call the hotline at (844) 680-0872.

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The Compliance Officer reports to and is a member of the Compliance Committee. The

Compliance Officer has the express authority to provide information directly to the Board of

Managers and to any Client Plan Sponsor at her discretion. Any termination of the Compliance

Officer shall require the majority consent of the Board of Managers.

The Compliance Committee is comprised of the Compliance Officer, a member of the

Board of Managers, the chief financial officer and the chief information and technology officer.

The member of the Board of Mangers shall serve as the Compliance Committee Chair. The

Compliance Committee will meet at least quarterly, or more often is necessary, develop strategies

to promote and detect compliance violations, assist in the creation and implementation and

monitoring of effective corrective actions, review the effectiveness of internal controls to ensure

compliance with Medicare regulations in daily operations, supporting the Compliance Officer’s

needs for sufficient staff and resources to carry out her duties, and all such other responsibilities

as set forth in the Medicare Managed Care Manual as shall be updated from time-to-time.

IV. Conducting appropriate training and education.

All P3 workforce members will receive compliance training and education applicable to

the requirements of their respective position within ninety (90) days of initial hiring and thereafter

a minimum of one time annually. More frequent compliance training and education will occur as

needed. Workforce members involved in specific areas of risk may be required to attend additional

training. All compliance training is mandatory and failure to participate may result in disciplinary

action, up to, and including, termination. Each workforce member will be required to sign an

acknowledgement indicating that he or she has attended training and has received and understands

the training materials and that he or she agrees to abide by the related principles.

Additionally, all FDRs are required by CMS to complete Medicare FWA and general

training on an annual basis. To fulfill this requirement, P3 requires all workforce members to

complete Gorman University’s fraud, waste and abuse and general compliance online training. To

access Gorman University’s fraud, waste and abuse training and general compliance training,

please go to:

http://lms.gormanhealthgroup.com/login/80/P3_Health_Partners.aspx.

Records of compliance training and education will be maintained by the Compliance

Officer for a period of ten (10) years of the time, attendance, topic, certificates of completion (if

applicable), and test scores of any tests administered to employees.

Workforce members are encouraged to contact the Compliance Officer with compliance

topics they would like to see highlighted in future training sessions in addition to the topics covered

by Gorman University.

V. Responding appropriately to detected offenses and developing corrective action.

Investigations of all reported compliance issues shall be coordinated by the Compliance

Officer in a prompt and appropriate manner and in accordance with P3’s Internal Investigations

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Policy. All internal investigations shall be commenced and when feasible completed, within two

weeks of report. All reports received, whether through a verbal or written report or as the result of

an audit shall be forwarded to the Compliance Officer, who shall prepare a Compliance Report

Form and direct an internal investigation. The Compliance Officer will be responsible for directing

the investigation of the alleged problem or incident and, as necessary, the Compliance Officer shall

work with P3’s legal counsel during investigations and report to the Compliance Committee,

Board of Managers as necessary and any Client Plan Sponsor.

The purpose of any investigation shall be to identify if applicable laws or regulations have

not been followed. Upon conclusion of an investigation, the Compliance Officer shall establish a

plan for correction of any non-compliance, as appropriate, shall create new policies to ensure future

compliance and shall make recommendations to P3’s management regarding appropriate

disciplinary actions. Additionally, P3 will comply with mandatory reporting requirements,

including to any Client Plan Sponsor, self-disclosure protocol, if applicable, and/or take other

corrective measures to address any compliance violations with all applicable laws and regulations.

If a potential criminal violation has occurred, P3 in coordination with its legal counsel will

promptly refer or disclose the related information to the appropriate government or law

enforcement agency.

VI. Developing open lines of communication.

Open lines of communication between P3 management, workforce members and the

Compliance Officer are essential to the successful implementation of the Compliance Plan,

effective training and educational activities, and to preventing non-compliant activities.

Workforce members have direct access to the Compliance Officer to make reports, to ask questions

about compliance policies or to ask other compliance-related questions. The Compliance Officer

will document all reports and questions and will share reports, questions and other information

with management as needed.

The Compliance Officer will communicate with P3 workforce members to promote

awareness and understanding of compliance activities and information through formal trainings,

e-mails, or by other appropriate methods to convey information. The Compliance Officer will

conduct interviews and compliance discussions on an on-going basis with P3 workforce members.

P3 encourages workforce members to be proactive in reporting compliance concerns or seeking

clarification in regard to compliance issues.

Communication regarding compliance matters may include physical postings of

information in P3 locations, email distributions, P3’s intranet, and individual and group meetings

with P3’s Compliance Officer.

P3 will report, and its employees understand they must report, any suspected or detected

noncompliance or potential FWA from the workforce to all appropriate Client Plan Sponsors.

VII. Enforcing disciplinary standards through well-publicized guidelines.

All P3 workforce members are required to comply with the Compliance Plan, P3’s policies

and procedures and all applicable laws and regulations.

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P3 handles corrective and disciplinary action on a case-by-case basis after consideration of

the specific circumstances. The corrective and disciplinary action will be more severe with

increased regulatory risk, with numerous occurrences of noncompliant activity and/or based on the

willfulness of the noncompliant conduct. Corrective action may include, but is not limited to,

additional training, additional monitoring/auditing, mentoring, adoption of a corrective action plan

and/or self-reporting and repayment of any overpayments to applicable governmental entities.

Disciplinary action may include, but is not limited to, verbal and written warnings, probation,

suspension, demotion, termination, restitution of damages and/or referral for criminal prosecution.

Failure to report suspected compliance issues will subject workforce members to possible

disciplinary action, up to, and including, termination. Reports may be made anonymously to the

Compliance Officer by phone. P3 management is prohibited from taking disciplinary action

against a workforce member for the good-faith reporting of a compliance issue. However, an

individual who makes a report containing an admission of personal wrongdoing is not protected

from discipline.

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This Compliance Plan, in conjunction with the various policies and procedures of P3, is

intended to provide guidance and a framework as to how these standards may be met. P3 workforce

members are encouraged to engage in discussion regarding compliance activities and ask any

questions that may arise regarding this Compliance Plan or any other related policy.

Questions about This Document Should be Directed to:

Compliance Officer/ Maria Nutile

Practice Manager: Phone: 702-307-4880

E-mail: [email protected]

P3 CMO: Amir Bacchus, M.D.

Phone: 702-910-3950

E-mail : [email protected]

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5. DOCUMENTATION / REFERENCES:

SUPPORTING DOCUMENTS

Appendix A – Regulatory and Legal Foundation of Compliance

CROSS-REFRENCED P&PS

Auditing and Monitoring Policy

Billing and Coding Compliance Policy

Compliance Report Form

Internal Investigations Policy

MANUAL

Medicare Managed Care Manual, Chapter 21, Compliance Program Guidelines

Prescription Drug Benefit Manual, Chapter 9, Compliance Program Guidelines

RELEVANT REGULATORY CITATIONS

42 C.F.R. § 422.503(b)(4)(vi)

42 C.F.R. § 423.504(b)(4)(vi)

6. HISTORY:

DATE REVISED BY REASON FOR REVISION/CONTENT

CHANGED

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APPENDIX A

REGULATORY AND LEGAL FOUNDATION OF COMPLIANCE

• Billing

o P3 will follow all federal and state laws and rules for all billing transactions.

• Fraud and Abuse

Many of the laws and regulations with which P3 must comply, including the Federal False

Claims Act (31 USC §§ 3729-3733) and the Federal Criminal False Claims Statutes (18 USC §§

287.1001), relate to the prevention of fraud and abuse which results in the misuse of funds in the

healthcare industry. In this context, “fraud” means a purposeful act of deceit or misrepresentation

to gain an unauthorized benefit. In this context, “abuse” means activities that are inconsistent with

standard business or medical practices, or which fail to meet professionally recognized standards

for health care, resulting in unnecessary costs to governmental or private healthcare plans.

Examples of healthcare fraud and abuse:

o Submitting a claim for services not provided

o Coding a service at a higher level than the actual service rendered

(also called “upcoding”) or coding a service at a lower level than the

actual service rendered

o Submitting a claim without supporting documentation

o Billing for non-covered services as covered services

o Providing a service that is not medically necessary

o Soliciting, receiving or offering to pay a kickback or bribe to induce

healthcare services

o Inaccurate medical record documentation to justify payment or a

higher payment amount

o Double billing resulting in duplicate payment

o Offering inappropriate inducements to patients

o Waiving copayments or deductibles without a good-faith

determination of financial need

Self-Referral Laws

P3 is committed to complying with state and federal laws addressing fraud and abuse. As

part of that commitment, P3 will structure all business arrangements in compliance with the state

and federal self-referral laws. P3 will ensure that all arrangements where P3 orders items or

services from an outside entity are based upon fair market value compensation. P3 shall neither

offer nor accept any remuneration for provider referrals it makes or receives.

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o Stark Law (42 USC § 1395nn)

The Physician Self-Referral Statute (or “Stark Law”) is a civil statute that prohibits

physicians from referring patients for certain designated health services (“DHS”) reimbursed

under a federal healthcare program to an entity with which the physician or a member of the

physician's immediate family has a financial relationship, unless an exception applies. It also

prohibits an entity from presenting or causing to be presented a bill or claim to anyone for a DHS

furnished as a result of a prohibited referral. Violations of the Stark Law may result in civil

monetary penalties and possible exclusion from federal healthcare programs.

o Anti-Kickback Statute (42 USC § 1320a-7b(b))

Pursuant to the Anti-Kickback Statute, it is a criminal offense to knowingly and willfully

offer, pay, solicit or receive any remuneration to induce the referral of business covered by a

Federal health care program. “Remuneration” is any benefit provided to a person to induce the

recipient to refer services and could be as simple as an agreement to send referrals back and forth

between providers. The Department of Health and Human Services (“DHHS”) has published safe

harbor regulations that define practices that are not subject to the Anti-Kickback Statute because

such practices would be unlikely to result in fraud or abuse. Failure to comply with a safe harbor

provision does not make an arrangement per se illegal because the statute is intent-based; however,

satisfying the provisions of a safe harbor ensures protection from prosecution.

In addition, P3 is committed to complying with the following:

▪ Title XVIII of the Social Security Act

▪ Medicare and Medicaid Regulations

▪ Patient Protection and Affordable Care Act (Pub. L. No 111-148, 124 Stat.

119)

▪ Health Insurance Portability and Accountability Act (HIPAA) (public Law

104-191) as modified by HITECH Act

▪ The Beneficiary Inducement Statute (42 USC § 1320a-7a(a)(5))

▪ Civil Monetary Penalties of the Social Security Act (42 USC § 1395w-

27(g))

▪ Prohibitions against employing or contracting with persons or entities that

have been excluded from doing business with the Federal Government (42

USC § 1395w-27(g)(1))(G))

▪ Fraud Enforcement and Recovery Act of 2009

▪ All sub-regulatory guidance produced by CMS and HHS such as manuals,

training materials, HPMS memos and guides

▪ Federal criminal law

▪ State specific laws related to self-referrals, anti-kickbacks and improper fee

splitting

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COMPLIANCE REFERRAL FORM

Instruction: The purpose of this form is to report complaints of fraud, waste, and abuse in the Medicare Parts C & D

Programs. P3 Health Partner’s Compliance Officer may contact you upon receipt of this complaint, so please be sure

to furnish sufficient contact information. To ensure compliance with all applicable laws, do not send Protected Health

Information (PHI) via email unless encrypted.

Please send completed document to [email protected].

COMPLIANCE REFERRAL FORM Date of Referral:

Type of Issue:

Medicare Advantage Issue (Part C)

Prescription Drug Benefit Issue (Part D)

Both Part C and Part D Issue

Complainant Contact Information:

Name

Telephone

Street Address

City

State

Zip Code

Email

Beneficiary Information:

Name

Member ID Number

Telephone

Street Address

City

State

Zip Code

Email

Date of Birth

Primary Language

Subject/Suspect Information:

Name

Provider ID Number

Tax ID Number

NPI Number

DEA Number

Medicare Provider ID Number

Telephone

Street Address

City

State

Zip Code

Email

Type of Business:

Primary Care

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Specialist

Pharmacy

Durable Medical Equipment

Laboratory

Radiology

Medical Supply

Ambulance

Other

Referral Submitted By:

Name

Telephone

Street Address

City

State

Zip Code

Email

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Description of Findings/Allegations: Please provide a detailed description of the nature of the fraud issue

including the following: description of fraudulent activity; how did you discover the issue; CPT codes involved;

States where the fraud activity took place; description of individuals and/or businesses involved in the alleged

illegal activity; dates that the fraud occurred; names and contact information for victims; and copies of

documentation regarding the fraudulent activity including letters, advertising, etc.

How was the issue discovered (data mining, phone call from member or provider, routine monitoring):

Description of the Incident:

• Who was involved:

• What occurred:

• When did it happen:

Please provide all relevant details including member’s XBU number, claim number, date of service, name of

provider, CPT code, etc.

What actions were taken before sending the referral to the Compliance Officer?*

• Reviewed part C claims:

• Reviewed part D claims:

• Contacted the member or provider:

• Contacted another internal department:

• Completed additional research not noted above:

Please give a brief description research completed and what was discovered by the research.

*Please submit all information that was collected and reviewed by you or your department as an

attachment to the email, such as medical records and correspondence.